Child Future Africa

This research was conducted for Child Future Africa (CFA), a non-profit organisation based in Mount Darwin, Mashonaland Central, Zimbabwe (see Figure 1: Map of Zimbabwe). CFA strives to enhance the menstrual experience of at-risk menstruating adolescents in Mashonaland Central, Zimbabwe, specifically in the district of Mount Darwin. CFA is an organisation that provides a home and access to school for at-risk children in the district of Mount Darwin, either temporarily or long-term. CFA’s main objective is to safeguard the welfare of orphaned and/or at-risk children in the community. According to a CFA representative (respondent 6), one of the issues that occurs and disturbs the welfare of menstruating persons in the communities being supported by CFA is the inadequate access to menstrual health education and facilities. When not educated properly, persons who menstruate are highly vulnerable to diseases and unwanted pregnancies. In order to enhance the menstrual health of persons, and specifically the adolescent persons who menstruate living in the communities where CFA operates, the menstrual health needs of these adolescents need to be met.

MHM in low- and middle-income countries

Menstruating community members in LMICs experience challenges regarding their menstrual needs (Kuhlmann et al., 2017; Hennegan & Montgomery, 2016; Phillips-Howard et al., 2015). As a result, menstruating persons often have to cope with the social and health implications of inadequate MHM. In rural LMIC settings, the unmet menstrual needs of impoverished menstruating persons can lead to increased physical and sexual harms. Even though there are commonalities between LMICs, the menstrual behaviour and strategies to handle menstruation differ by culture and age. A variety of items are used as menstrual products by at-risk menstruating persons (especially among younger persons), such as old cloths, grass, cotton wool, plastic, socks, and paper. Menstruating persons recognise that the way their menstruation is managed may be unhygienic but lack better alternatives (Kuhlmann et al., 2017; Phillips-Howard et al., 2015).

MHM and constraints faced by school-going menstruating adolescents

Schools in LMICs face substantial barriers to achieving adequate MHM and WASH baselines. In 2013, 43% of LMICs had water coverage in schools and 46% of LMICs had sanitation coverage in schools (Sommer et al., 2015). In Zimbabwe, several barriers exist to hygienic practices in MHM. In a study conducted by Ndlovu and Bhala (2016), the following challenges were mentioned by respondents (respondents consist of stakeholders working directly or indirectly with the school-going menstruating adolescents and women drawn from community structures):

• 30% indicated water challenges in terms of sanitary facilities at school;
• 35% indicated the majority of the girls could not afford sanitary supplies, as they were priced beyond their capacity;
• 10% of girls had no underwear, which meant they would rather stay at home than face embarrassment at school;
• 15% indicated they had access to proper disposal facilities; and
• 5% complained of a lack of reusable sanitary supplies (Ndlovu & Bhala, 2016, p. 5).

The most recent studies reported that most sanitary facilities at schools in Zimbabwe were inappropriate regarding privacy; toilets lacked access to water, handwashing facilities, disposal facilities, doors, and/or were poorly maintained, are often unclean, unsafe, and too few in number (Ndlovu & Bhala, 2016; Sommer & Sahin, 2013). If there is available water, it is often located away from the bathroom stall, preventing menstruating persons from privately washing blood off their hands or clothes. Furthermore, latrines lack opportunities for disposal of menstrual products and ultimately prevent menstruating persons from having a dignified and safe menstruation period (Sommer & Sahin, 2013). Hence, these inappropriate sanitary facilities are a constraint in managing the menstruation and is especially challenging for menstruating persons in most rural communities in Zimbabwe (Ndlovu & Bhala, 2016).

Moreover, sanitary facilities in schools are a key determinant in school attendance of menstruating students. A lack of such facilities significantly increases the challenges school-going menstruating persons face with respect to managing their menstrual hygiene (Kuhlmann et al., 2017; Ndlovu & Bhala, 2016). Menstruation interrupts a menstruating pupil’s capability to properly participate in school and progress academically (Kuhlmann et al., 2017; Ndlovu & Bhala, 2016; Sommer, 2015; Sommer & Sahin, 2013). Furthermore, earlier menarche and the greater emphasis on education for girls mean that many adolescent menstruating girls go to school while menstruating. A typical menstrual cycle lasts 25 to 30 days, in which bleeding occurs for four to six days. Thus, menstruating persons experience menstrual bleeding on at least a few school days each year. MHM is therefore increasingly important (despite often unrecognised) and intertwined with girls’ empowerment, education, and social development (Kuhlmann et al., 2017).

According to Ndlovu and Bhala (2016), 57% of menstruating persons feel a lack of adequate support from family members and school, which leads to increased absenteeism. They found that, in total, 30% of menstruating persons indicated low performance during menstruation, and 20% of menstruating persons indicated a lack of concentration. Furthermore, 17% cited low class participation and low extracurricular activity participation during menses. Participants of the study indicated feeling anxious, discriminated against, and low self-esteem. All these factors have a negative contribution to a menstruating person’s educational performance and health. Ultimately, poor MHM can result in poor school results and therefore, an inability to access opportunities after school (Ndlovu & Bhala, 2016). Furthermore, Phillips-Howard et al. (2015) mentioned the issue of leakage and odour due to poor MHM, which consequentially prevents menstruating persons from fully engaging or even attending school during menstruation.

MHM and the connection to SRHR

MHM and sexual and reproductive health and rights (SRHR) are strongly interlinked, with MHM increasingly recognised as a crucial aspect of SRHR. Reproductive and sexual health programs need to provide support in the provision of affordable menstrual products, in order to economically empower menstruating persons and thus prevent harmful ways of acquiring money to buy menstrual products (Phillips-Howard et al., 2015). Generally, persons who menstruate are reliant on the men in their lives for access to menstrual products, and this often results in menstruating persons lacking the menstrual products they need due to the stigmatisation of menstruation and lack of financial resources. Likewise, in many households in rural areas in LMICs, the relatively high costs of commercial sanitary pads have to compete against other needed items in the family, such as food (Phillips-Howard et al., 2015).

Furthermore, the cultural implications of menstruation that occur in certain, often rural, regions in Zimbabwe, can have a negative impact on the menstruating person’s sexual and reproductive health. Unhygienic practices resulting from having to hide the menstruation due to cultural beliefs can lead to reduced reproductive health. In a district in southern Zimbabwe, menstruating persons are perceived as dirty during menstruation. During menses, menstruating persons are therefore not allowed to cook, bathe, or participate in public gatherings, such as church gatherings. Persons who menstruate therefore can be put in the position to having to hide their menstruation, which often leads to unhygienic practices that are harmful to their reproductive and menstrual health (Kuhlmann et al., 2017; Tamiru et al., 2015).

Despite growing global and local attention for MHM and the impact the lack of MHM has on menstruating persons, a significant knowledge gap regarding menstruation persists. Often menstruating persons find themselves in a setting that does not meet proper hygiene standards and lack access to proper information and support regarding the menstruation. Additionally, cultural taboos concerning menstruation compound this problem (Sommer & Sahin, 2013).

Integrated model of menstrual experience and hygiene management

Hennegan et al. (2019) developed an integrated model of menstrual experience after conducting a systematic review and qualitative meta-synthesis of extant qualitative studies of menstrual experience. The integrated model hypothesizes directional pathways for future studies and for program and policy development to improve women’s and girl’s health and well-being. Based on literature review on menstrual experience and hygiene management of adolescents in Zimbabwe and other LIMCs, this study focused on four of the themes included in the integrated model of Hennegan et al. (2019). The four themes of knowledge, physical environment, economic environment and confidence became the basis for the conceptual model of this study (see Figure 2: Conceptual Model).

The theme of ‘physical environment’ pertains to water and sanitation facilities and infrastructure as well as disposal facilities. Sanitary facilities in schools are crucial for school attendance of menstruating persons and the lack thereof can become a barrier to maintaining hygiene and health (Kuhlmann et al., 2017; Ndlovu & Bhala, 2016; Sommer et al., 2015). The theme of ‘economic environment’ pertains to the affordability and availability of menstrual products. Menstruating persons need access to proper menstrual products and the lack of access and availability can impair their menstrual experience (Hennegan & Montgomery, 2016; Kuhlmann et al., 2017; Phillis-Howard et al., 2015). The third theme, ‘knowledge’, pertains to knowledge of menstrual biology, reproduction, accuracy of taboos, and practical menstrual management. MHM intervention programs can increase knowledge in order to improve menstrual health practices (Kuhlmann et al., 2017). Furthermore, increasing knowledge through software interventions² can improve MHM practices, eliminate confusion, and (cultural) misconceptions (Hennegan & Montgomery, 2016).

The three themes of ‘knowledge’, ‘physical environment’ and ‘economic environment’ are crucial when aiming to improve the confidence a menstruating person experiences during their period, thus enhancing the menstrual experience. This relates directly to the last theme of ‘confidence’ which pertains to the ability to manage menstruation, and to engage in other activities while menstruating.

Data collection

The main data collection method consisted of semi-structured interviews with 11 experts and key informants in menstrual health. Additionally, five at-risk menstruating adolescents from rural Mashonaland Central were interviewed using a qualitative questionnaire.

Semi-structured interviews were used as a way to retrieve in-depth insights into the needs of menstruating persons in LMICs regarding MHM and to have opportunity for exploration during the interview. The four overall themes of this research, based on the conceptual model, were used to structure the interview questions (knowledge, physical environment, economic environment, and confidence), while leaving room for emergent topics.

A qualitative questionnaire was administered to five at-risk menstruating adolescents in Mashonaland Central, Zimbabwe. This was done to get the perspective of menstruating adolescents on their needs and wants regarding MHM. In this research, it was crucial to include the target population consisting of Zimbabwean menstruating adolescents from Mashonaland Central as much as possible despite the limitations (see ‘Limitations’), in order to ensure that their perspectives, voices, and needs were considered.

Sampling

For the expert and key-informant interviews, purposive sampling and snowball sampling were used. Key informants were defined as respondents that were able to provide a better insight on the needs in MHM regarding menstruating adolescents in specifically Mashonaland Central, and experts were defined as respondents that were able to provide valuable insights on the needs in MHM of menstruating persons in rural areas of other LMICs. Purposive sampling was used for identifying experts and key-informants on MHM practices in Mashonaland Central, Zimbabwe, and comparable LMICs. Experts and key informants therefore needed to have a thorough understanding of MHM practices in LMICs and be available for interviews conducted virtually. Snowball sampling was used to identify additional experts or key informants for the interviews. Interviewees referred the researcher to others in their network to contribute to a more diverse sample of experts and key informants in MHM. Furthermore, the researcher stayed in close contact with local stakeholders in Mashonaland Central, to retrieve additional data regarding specific context-related aspects relevant for the research such as information on what lavatories are commonly used, or what interventions could be impactful specifically to Mashonaland Central. Local stakeholders furthermore assisted in identifying suitable experts or key-informant interview participants.

The five adolescents who answered the qualitative questionnaire were recruited through snowball sampling with the help of a local secondary school teacher. They were all students of a local secondary school in Mashonaland Central. All five participants were identified as eligible for the questionnaire because they are part of the target population, being at-risk menstruating adolescents in Mashonaland Central, Zimbabwe. As the qualitative questionnaire had to be answered online, it was imperative that all five adolescents had access to a working phone with internet connection to submit answers. However, as can be read in the recommendations of this study, this sample size is very small, and it is highly recommended to have a larger sample size of the target population and have in-depth and face-to-face interviews in future research.

Data analysis

All raw data derived from the interviews was summarised without excluding any data. In the analysis process, a manual color-coding was done first and followed by analysing the data in the qualitative data analysis programme MAXQDA (version 2020). In MAXQDA, the data was analysed more in depth through expanding the codes and cross-referencing. Furthermore, data retrieved from the questionnaire was analysed in MAXQDA as well, using the same codes as for the interviews. For this coding, a deductive coding method was adopted, and emerging coding was done additionally (Stuckey, 2015). The codes were based on the conceptual model used in this study and had a clear description of the meaning of each code.

Knowledge

Menstruating adolescents need to have access to an adequate provision of knowledge, not only knowledge about the menstrual biology and anatomy, but also about puberty education, hormones, pain, menstrual products and how they are used, and so on. According to respondent 1, a staff from an NGO that campaigns for female education in Zimbabwe, ‘It is important to provide the girl information about her body and help her to appreciate her body so that she can understand her body is changing.’ Correspondingly, respondent 8, a menstrual health doctoral researcher, recognised the importance of integrating the biological aspect of menstruation with the day-to-day effects of menstruation and emphasised on the missed opportunity regarding providing knowledge on hormonal changes, mood changes, pain, and physical changes due to menstruation. This was supported by respondent 5, a senior education specialist in a foundation, who lamented that, ‘Often adolescents do not know how menstruation actually works, when you are fertile, and what it means when you are bleeding’. Moreover, there are many menstruating persons suffering from serious menstrual health concerns. But because they do not recognize the seriousness of their health issues, they do not visit a health practitioner. Respondent 8 said, ‘There are so many women and girls suffering from serious health concerns, but they just think: oh, it’s my period, I need to suffer; that is what I am born for as a woman’. Hence, the menstruating persons need to be taught about fertility and reproductive health in order to increase body literacy and overall menstrual health and empowerment.

In providing knowledge to the menstruating persons, respondent 8 believes that the ecosystem around the menstruating adolescents needs to support them in the provision of this knowledge, which can come from various sources.⁴ This entails taking the local context into account when providing knowledge, and ensuring access of menstruating adolescents in rural areas to adequate knowledge through different channels specifically designed to the local contexts. Moreover, it is important to involve community members, including boys and men, in any MHM intervention, according to the majority of respondents. They explained that boys and men need to be engaged in any form of MHM education because all people should be educated about menstruation being a natural and normal thing. Respondent 9, a doctoral researcher on SRHR in Uganda, stressed the importance to address boys and girls together in order to facilitate a valuable discussion between the sexes. In summary, it means that when providing MHM education, boys and men should be part of the target group of the educational program or intervention. Furthermore, when creating and providing programs for MHM education, it is crucial to take a bottom-up approach and engage the target group and community in every step of creating suitable, context-sensitive programs.

One of the challenges in MHM education is that menstruation is seen as a taboo topic in a lot of countries. According to respondent 8, MHM education should take into account the layers of social narratives around menstruation and aim to change the narrative of menstruation as a taboo topic into a neutral or positive one. Respondent 5 believes that factual knowledge can be a powerful tool to refute those myths and misunderstandings. Echoing the ecosystems approach, respondent 8 called for the involvement of community members in demystifying taboos and stigmas around menstruation.

Lastly, respondent 10, the head of a global program to end period stigma, recommended an approach that has worked in projects, where on the community level a bridge is built between cultural sensitivities and addressing why the people believe in certain things. A key element of this approach is its interdisciplinarity, which includes working together with all parties involved in the ecosystem. It uses entertainment education, that is discussing serious topics through light mediums such as songs or play. Respondent 9 endorsed entertainment education, particularly as a means to reduce the taboo around menstruation, as it enables participants to discuss a sensitive topic in a popular format that can make the topic easier to talk about.

Physical environment

All respondents mentioned the importance of access to clean water. According to respondent 7, a MHM and WASH expert from Kenya, safe water needs to be available to wash hands, for bathing, and for cleaning different menstrual products. However, respondent 1 mentioned that the provision of adequate and safe water is not a given, but something that has to be provided. While there is water available in some schools in rural areas in Zimbabwe, often it is not available in the bathroom itself, according to respondent 2, a secondary teacher in Mashonaland. This was seconded by adolescent participant 2 who stressed the importance of access to water and a disposal facility inside the lavatory. On top of water availability in the bathroom, responded 8 added that soap and a towel for drying need to be available.

The reality remains that a person usually has to travel a long distance to access clean and safe water. In some cases, girls walk up to five kilometres to fetch water according to respondent 11, a government social worker. Respondent 6, a primary school teacher, illustrated the difficulty of distance in the context of her community in Mount Darwin, Mashonaland Central. This area is remote and is subject to a lot of poverty that it is a big challenge to get the required products needed to manage menstruation well to the communities. This again highlights the importance of taking the local context and the available resources in the area into account in MHM interventions.

While many things can be done in MHM education, respondents 1 and 5 argued that if there is a lack of sufficient WASH facilities, then a menstruating adolescent is still not able to participate in school during her menstrual period. In fact, respondent 11 revealed that many families in the rural areas share Blair toilets or still use the bush system (open ablution). To address this, respondent 6 suggested that bathrooms and toilets with water inside or Blair toilets need to be available at the minimum. Respondents 7 and 9 insisted on having access to all facilities related to WASH infrastructure, both in school and in the community.

Another important aspect is privacy. Respondent 6 suggested special compartments available only for menstruating adolescents. These compartments need to provide the possibility for bathing and cleaning and changing menstrual products. Respondent 8 added that schools need to provide the menstruating adolescents with a safe place where they can change, throw away or wash and dry a pad. The adolescent participants in this study supported these suggestions, and added specific details. For instance, adolescent participants 3 and 5 mentioned the placement of a hook so that clothes can be hung in order to prevent them from getting dirty. Moreover, all adolescent participants in this study stressed the need for a specific teacher available for questions or help in order to manage their menstruation in school.

Economic environment

Menstrual products need to be affordable, available, of high quality, and made of safe materials. Respondent 8 stressed that the ‘high quality and reliability of the product, whether disposable or reusable, and the ability to wash and take care of the product, on top of the accessibility and affordability’ are important characteristics of menstrual products. For respondent 8, it is also important to consider whether the product allows the persons using it to feel dry, to move, to play, to exercise, as they would when not menstruating. Thus, there is the functionality aspect of a product on one hand, and accessibility on the other that one considers when choosing a menstrual product.

Menstruating adolescents in rural areas often choose disposable menstrual products due to its comfortability and accessibility. Moreover, there are context-specific factors at play: the affordability and availability of the products in a specific environment (taking into account the remoteness of certain areas); the awareness of the family on what menstrual products to buy and where to buy these; and whether menstrual products are included in the household’s budget.

Respondent 7 stated that it is necessary to make all menstrual products available, and adopt a pro-choice approach. ‘You cannot force anyone to use a specific product. All products need to be available so that the person who menstruates can choose what works for them, whether that is one product or multiple different products.’ Aside from making all menstrual products available, it is crucial to make them affordable and, in the opinion of respondent 1, this is where government support is crucial. To address the lack of access to affordable menstrual products, respondent 11 suggested the provision of hygiene kits to those from low- to middle-income families. Another important measure, as suggested by respondent 8, is subsidising products, which can be done by NGOs that work in LMICs. Subsidies are a good alternative to distributing products for free, since free products could be seen as ‘for the poor’ and of low quality. Other respondents agreed that menstrual products should not be given out for free for reasons mentioned by respondent 8, and added that it is not a sustainable business model and is not effective in the long-term.

According to respondent 10, if governments are not able to provide sanitary products, either for free or for a reduced price, then alternative measures are needed to ensure affordability of menstrual products. An idea that respondent 10 proposed is to introduce reusable products connected to income-generating projects. For respondent 5, it is important to have resources to produce pads locally, aside from promoting reusable products. As schools often lack the funds to provide menstrual products, respondent 6 emphasized the need for parents to be aware of the importance of MHM so they could adequately provide the materials, time, and support their adolescent daughters need during menstruation.

Confidence

Discomfort and pain is commonly experienced by menstruating adolescents, and this leads to a lack of confidence. This is often due to an inadequate supply of menstrual products, consisting of not only sanitary pads but also undergarments and pain medication. This was confirmed by the adolescent participants in this study. Reliable and varied menstrual products need to be available for menstruating adolescents so they could take on normal daily activities without feelings of discomfort, and with confidence.

According to respondent 1, confidence can also be increased by giving the menstruating adolescents information and providing them with the necessary support in terms of MHM materials and resources. In doing so, menstruating adolescents can feel like it is any other day even during their menses, and it is not necessary to feel insecure because of something the body is naturally doing. Body literacy is a crucial aspect in this process, which again comes back to providing the adolescents with sufficient education.

Moreover, as stressed by respondent 10, menstruating adolescents need to be able to share and discuss feelings and experiences during and regarding menstruation in order to feel confident. Besides, there needs to be space for talking and expressing feelings about menstruation. As respondent 5 said, as soon as an open conversation on menstruation can take place and the attitudes towards menstruation start to change, a change in behaviour can follow. This allows them to better manage menstruation and perform normal daily activities, henceforth, increasing the level of confidence of menstruating adolescents.